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MODIFIED LEARNER ENROLLMENT AND SURVEY FORM
THIS FORM IS NOT FOR SALE
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Instructions:
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1. This enrollment suurvey shhall be answered by the parent/guardian of the learner.
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2. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters for items not applicable, write N/A.
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3. For questions/clarifications, please ask for the assistance of the teacher/person-in-charge.
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A. GRADE LEVEL AND SCHOOL INFORMATION
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A1. School Year
-A2. Check the appropriate boxes only
No LRN
With LRN
A3.
Returning (Balik-Aral)
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A4. Grade level to enroll:
A7. Last school attended:
A8. School ID:
A11. School to enroll in:
A12. School ID
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A5. Last grade level completed:
A9. School address:
A13. School Address:
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A6. Last school year completed:
A10. School type:
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Public
Private
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FOR SENIOR HIGH SCHOOL ONLY:
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A14. Semester (1st/2nd):
A15. Track:
A16. Strand (If any):
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B. STUDENT INFORMATION
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B1. PSA Birth Certificate No.
(if available upon enrolment)		B2. Learner Reference Number (LRN)
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B3. LAST NAME
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B4. FIRST NAME
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B5. MIDDLE NAME
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B6. EXTENSION NAME e.g. Jr., III (if applicable)
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B7. Date of Birth
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For Learners with Special Education Needs
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(Month/Day/Year)
B14. Does the learner have special education needs? (i.e. physical,
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mental, social disability, medical condition, giftedness, among others)
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B8. AgeB9. Sex MaleFemale
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Yes
No
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B10. Belonging to Indigenous People (IP)
Yes
No
B15. If yes, please specify:
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Community/Indigenous Cultural Community
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B11. If yes, please specifiy:
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B16. Do you have any assistive technology devices available at home?
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B12. Mother Tongue:
(i.e. screen reader, Braille, DAISY)
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B13. Religion:
Yes
No
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B18. Email Address:
B17. If yes, please specify:
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ADDRESS
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B19. House Number and Street
B20. Subdivision/Village/Zone
B21. Barangay
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B22. City/Municipality
B23. Province
B24. Region
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C. PARENT/GUARDIAN INFORMATION
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FatherMotherGuardian
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C1. Full Name (last name, first name, middle name)
C4. Full Maiden Name (last name, first name, middle name)
C7. Full Name (last name, first name, middle name)
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C2. Highest Educational Attainment
C5. Highest Educational Attainment
C8. Highest Educational Attainment
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No Formal Schooling
No Formal Schooling
No Formal Schooling
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No Formal Schooling but able to read
No Formal Schooling but able to read
No Formal Schooling but able to read
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and write
and write
and write
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Elementary level
Elementary level
Elementary level
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Elementary Graduate
Elementary Graduate
Elementary Graduate
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High School level
High School level
High School level
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High School Graduate
High School Graduate
High School Graduate
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After High School Education
After High School Education
After High School Education
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(College / Post Grad) or
(College / Post Grad) or
(College / Post Grad) or
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Technical Vocational
Technical Vocational
Technical Vocational
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C3. Contact numbers (Cellphone/telephone) / Email AddressC6. Contact numbers (Cellphone/telephone) / Email AddressC9. Contact numbers (Cellphone/telephone) / Email Address
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C10. Is your family a beneficiary of 4Ps?
Yes
No
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